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Pediatric Pulmonary Hemorrhage 
vs. Extrapulmonary Bleeding in 
the Differential Diagnosis of 
Hemoptysis 
 
Michael Vaiman1, Baruch Klin2, 
Noa Rosenfeld3, Ibrahim Abu-
Kishk3 
 
1Department of Ear Nose and Throat - 
Head and Neck Surgery, Assaf Harofeh 
Medical Center, Sackler Faculty of 
Medicine, Tel-Aviv University, Tel-Aviv, 
Israel;  
2Department of Pediatric Surgery, Assaf 
Harofeh Medical Center, Sackler Faculty 
of Medicine, Tel-Aviv University, Tel-
Aviv, Israel;  
3Pediatric Intensive Care Unit, Assaf 
Harofeh Medical Center, Sackler Faculty 
of Medicine, Tel-Aviv University, Tel-
Aviv, Israel  

 
Vol. 6, No. 1 (2017)   |   ISSN 2166-7403 (online)  
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Abstract 

Introduction: Hemoptysis is an important symptom which causes a major concern, and warrants immediate diagnostic attention. 
The authors compared a group of patients with pediatric pulmonary hemorrhage with pediatric patients diagnosed with 
extrapulmonary bleeding focusing on differences in etiology, outcome and differential diagnosis of hemoptysis. 
Methods: We performed the retrospective analysis of medical charts of 134 pediatric patients admitted to the Emergency 
Department because of pulmonary and extrapulmonary hemorrhage and were diagnosed with suspected hemoptysis or developed 
hemoptysis (ICD10-CM code R04.2). The cases with pulmonary hemorrhage (Group 1) were compared with cases of 
extrapulmonary bleeding (Group 2) using the Fisher Exact test or Pearson’s χ2 test for categorical variables. The t-test was used to 
assess differences between continuous variables of the patients in the two groups. 
Results: Bloody cough was the presenting symptom in 73.9% of cases. 30 patients had pulmonary hemorrhage (Group 1), while 
104 patients had extrapulmonary bleeding (Group 2). The underlying causes of bleeding in Group 2 included epistaxis, 
inflammatory diseases of nasopharynx and larynx, foreign bodies, gingivitis, and hypertrophy of adenoids. Mortality rate was 10% 
in Group 1, whereas Group 2 did not have any mortality outcomes during the observation period. Etiologycal factors were 
significantly different between hemoptysis and extrapulmonary bleeding in children 
Conclusions: Our research suggested that pulmonary and extrapulmonary bleeding are two conditions that differ significantly and 
cannot be unified under one diagnostic code. It is important to differentiate between focal and diffuse cases, and between pulmonary 
and extrapulmonary hemorrhage due to the diversity of clinical courses and outcomes.  

Keywords: Pulmonary Hemorrhage; Extrapulmonary Bleeding; Hemoptysis, Epistaxis; Pediatric 

Pediatric Pulmonary Hemorrhage vs. 
Extrapulmonary Bleeding in the 
Differential Diagnosis of Hemoptysis 
 
Michael Vaiman1, Baruch Klin2, Noa 
Rosenfeld3, Ibrahim Abu-Kishk3 
 
1Department of Ear Nose and Throat - Head 
and Neck Surgery, Assaf Harofeh Medical 
Center, Sackler Faculty of Medicine, Tel-
Aviv, University, Tel-Aviv Israel;  
2Department of Pediatric Surgery, Assaf 
Harofeh Medical Center, Sackler Faculty of 
Medicine, Tel-Aviv University, Tel-Aviv, 
Israel;  
3Pediatric Intensive Care Unit, Assaf Harofeh 
Medical Center, Sackler Faculty of Medicine, 
Tel-Aviv University, Tel-Aviv, Israel 

Research 

Hemoptysis is an important symptom which 
causes major concern in both patients and physicians, and 
warrants immediate diagnostic attention. The incidence 
of pediatric hemoptysis in the general population is not 
well established because hemoptysis is a symptom 
associated with numerous diseases and no special 
symptom-related epidemiological report has been 
published so far. As a result, hemoptysis is a term with 
numerous definitions that only partially overlap with 
each other. The narrowest medical dictionary definition 
describes hemoptysis as the expectoration of blood-
tinged sputum derived from the lungs or bronchial tubes 
as a result of pulmonary or bronchial hemorrhage.1  

Hemoptysis is a rare symptom in children.2 
Since children tend to swallow their sputum, bloody 
sputum may go unnoticed unless it is substantial.3 
Hemoptysis in adults is most often caused by bronchitis, 
tumors, tuberculosis or bronchiectasis.4,5 However, 

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among the pediatric population, blood-tinged sputum is 
most likely to be secondary to infection, foreign body 
aspiration, or tracheostomy related problems.2,6,7 In 
1990s, cystic fibrosis and congenital heart diseases 
(mitral stenosis) were reported as predominant etiologic 
factors for hemoptysis.8 Currently,  various etiologies are 
suggested including idiopathic pulmonary 
hemosiderosis, pulmonary vascular malformation, 
pulmonary arteriovenous fistula, bronchiectasis, 
pulmonary tuberculosis, and lung tumors, with cystic 
fibrosis accounting for only 5% of cases.9  

Extrapulmonary bleeding, sometimes referred 
as pseudohemoptysis, is a common umbrella term for all 
types of hemorrhage not derived from the lungs or 
bronchial tubes and excluding hematemesis.  Since both 
pulmonary and extrapulmonary types of bleeding can be 
dangerous and sometimes life-threatening, physicians 
require adequate knowledge in this area in order to 
provide rapid and effective interventions.   

While the above definition of hemoptysis 
clearly localizes the lower respiratory tract as the place 
of origin of the pathology, this restriction is not always 
taken into account in the clinical practice. Emerging 
literature included “upper airway bleeding” and 
“pharyngitis”10 as well as “nasopharyngeal bleeding”11 to 
describe the etiology of hemoptysis. These inclusions 
might be based on wider definitions of hemoptysis as 
“the expectoration from the respiratory tract of both 
blood-streaked sputum and gross blood”12 or “coughing 
up blood as a result of bleeding from the respiratory 
tract.”13 Finally, hemoptysis is sometimes defined as just 
“the expectoration of blood or blood-tinged sputum.”2 
This definition is the most inaccurate because it mixes 
hemoptysis and hematemesis. The differential diagnosis 
between hemoptysis and hematemesis is relatively 
simple starting from alkaline or acidic pH of the blood-
containing sputum. The difference was well described 
recently,11,14 but it seems that differential diagnosis 
between hemoptysis/pulmonary hemorrhage and 
extrapulmonary bleeding requires further clarification.  

Previously published literature suggests that 
“hemoptysis is rare in children and adolescents”15,16, 
which highlights the gap in the literature that this paper 
will attempt to address. The purpose of this study was to 
review 14 years of experience with hemoptysis and 
extrapulmonary bleeding among children in a secondary 
medical center. We will also compare the frequencies of 
diagnostic presentations between pediatric pulmonary 
hemorrhage and extrapulmonary bleeding with an 
emphasis on etiology, clinical course, outcome and 
differential diagnosis between them, as well as analyzing 
possible correlations between patents’ personal 
characteristics and etiology of the bleeding. In the present 
article, the term “hemoptysis” is used as “the 
expectoration of blood-tinged sputum derived from the 
lungs or bronchial tubes as a result of pulmonary or 
bronchial hemorrhage”, and the importance of the proper 
definition is addressed further in the Discussion section.  

 

Methods 

Participants 

Institutional review board approval was 
obtained for this study from Assaf HaRofeh Medical 
Center Ethical Board (Helsinki Registration #225-09). 
The authors conducted a retrospective chart review of 
pediatric patients, aged 1-18, who were admitted to 
Pediatric Intensive Care Unit, Ear, Nose, and Throat-
Head and Neck Surgery Department, and Pediatric 
Surgery Department, Assaf HaRofeh Medical Center, 
Israel, because of suspected hemoptysis or developed 
hemoptysis (ICD10-CM code R04.2) between January 
2004 and December 2016. Charts of the patients who 
were hospitalized and who were discharged from the 
Emergency Department were analyzed according to the 
inclusion criteria. The analysis focused on identifying 
similarities/differences in the general data (age, sex, 
number of cases), etiology, symptoms, clinical and 
laboratory findings, and outcomes that might be 
important for differential diagnosis.

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Variables     Pulmonary bleeding    Extrapulmonary bleeding   p 
General 
N     22.4% (n=30)    77.6% (n=104)     0.02* 
M/F      16/14      56/48       0.44* 
Median age, years  7.6       5.1          0.03** 
 
Diagnostic findings 
Bloody cough    73.3% (n=22)    74% (n=77)     0.9* 
Diffuse lung infiltrations 53.3% (n=16)    10.6% (n=11)     0.02* 
Focal pathology in lungs 60% (n=18)    0%       <0.01* 
Positive sputum cultures 13.3% (n=4)    0%       <0.01* 
Positive blood cultures  6.7% (n=2)     0%       <0.01* 
Foreign body    16.5% (n=5)    11.54% (n=12)     0.05* 
Symptomatic anemia  33% (n=10)    8.7% (n=9)      0.03* 
 
Management 
Antibiotic treatment  60% (n=18)    35.6% (n=37)     0.03* 
Mechanical respiratory 
support    33% (n=10)    0%       <0.01* 
Packed cell transfusion  33% (n=10)    8.7% (n=9)      0.02* 
 
Outcome 
Cessation of the  
hemorrhage   80% (n=24)    100% (n=104)     0.07* 
Surgery or transfer  10% (n=3)     0%       <0.01* 
Mortality rate    10% (n=3)     0%       <0.01* 
*p-values were calculated using Chi square or Fisher’s  test 
** p-values were calculated using t-test 

Table 1. Comparison between patients with pulmonary and extrapulmonary bleeding. 

Patients were identified using the hospital computerized 
database and were categorized into two groups: Group 1, 
which included patients with confirmed hemoptysis as a 
result of pulmonary or bronchial hemorrhage; and Group 
2, which included patients with extrapulmonary bleeding.  

The main inclusion criterion for charts was the 
presence of complete and detailed data that would be 
sufficient for differential diagnosis. These included 
detailed health history, clinical data with adequate 

description of respiratory or hemodynamic symptoms, 
chest radiography, and bronchoscopy and/or direct 
laryngoscopy or nasopharyngoscopy. Data on 
microbiology, serology (including serology for 
vasculitis) and chest computed tomography (CT), were 
also analyzed. Exclusion criteria were iatrogenic 
bleeding, hematemesis, cases with trauma that caused 
both internal and external bleeding, and incomplete data 
in the charts.  

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Etiology      Extrapulmonary (n=104)  Pulmonary bleeding (n=30)  p*  

Infections/inflammations  55 (53%)     15 (50%)     0.87 

Foreign body     12 (11.54%)    5 (16.7%)     0.05 

Tonsils/adenoids hypertrophy 10 (9.6%)     0 (0%)     <0.01 

Bronchiectasis    0 (0%)     5 (16.7%)     <0.01 

Vascular malformation    0 (0%)     2 (6.7%)     <0.01 

Idiopathic/traumatic epistaxis  23 (22%)     0 (0%)     <0.01 

Massive aspiration    0 (0%)     2 (6.7%)     <0.01 

Toxic effect (cocaine)   0 (0%)     1 (3.3%)     - 

Severe cough 
of unknown origin   4 (3.87%)     0 (0%)     <0.01 
*p-values were calculated using Chi square or Fisher’s  test 

Table 2. Etiology of hemoptysis and extrapulmonary bleeding in children.  

 

Statistical analysis 

Descriptive statistics were used to describe the 
basic data trends. Cases with pulmonary hemorrhage 
were compared with cases of extrapulmonary bleeding 
using the Fisher’s Exact test or Pearson’s χ2 test for 
categorical variables (gender, diagnostic findings, 
management, outcome) and t-test for continuous variable 
(age). The Pearson correlation coefficient was calculated 
to detect possible connections between analyzed 
variables and gender and age of the patients. The data 
were analysed using SPSS, Standard version 17.0 (SPSS, 
Chicago, IL, 2007). The level of significance for all 
analyses was set at P<0.05. 

 

Results 

Over the course of 12 years of observation134 
pediatric patients with suspected hemoptysis were 
admitted to the Medical Center Emergency Department 
(0.2% of all pediatric admissions to the Emergency 

Department). Of them, 86 (64.2%) were hospitalized for 
24 hours or more. The patients had a median age of 5.6 
years (range 0.15-17), with no difference between 
genders (p=0.86). Bloody cough was the presenting 
symptom in 73.9% (n=99), the remainder later developed 
a non-cough related hemorrhage. Further hospital 
investigation revealed that 30 out of 134 patients (22.4%) 
presented with expectoration of blood-tinged sputum as 
a result of pulmonary or bronchial hemorrhage, while the 
rest had extrapulmonary bleeding (p=0.02). All patients 
underwent an otolaryngology evaluation including 
endoscopy/nasopharyngoscopy that excluded or 
confirmed upper airway sources of bleeding. In all 
analyzed patient records, the routine blood-containing 
sputum pH test was performed to rule out hematemesis. 
Chest radiographs were important for classifying diffuse 
or focal disease, with diffuse pulmonary hemorrhage 
being a more severe condition (Fig. 1A). Bronchoscopy 
was performed mostly in cases with focal signs detected 
on a chest X-ray images in order to explore the source  

 

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Pt Chest Imaging           Bronchoscopy 

1. Bronchiectasis RML and lingual                    Normal 
2. Bronchial wall thickening RML & lingual 
3. LLL consolidation                                          Normal  
4. RUL consolidation and cavitations                Partially obstructed main bronchus RUL 
5. Diffuse infiltrates 
6. LLL Infiltrates                                                Normal  
7. Diffuse alveolar infiltrates                              Normal  
8. RUL and LLL pneumonia 
9. Diffuse infiltrates                                            Was not performed because of suffocation 
10. Bilateral basal infiltrates 
11. Bilateral infiltrates 
12. Mild RLL infiltrates                                       Foreign body 
13. Right diffuse infiltrates                                   Foreign body 
14. RLL atelectasis                                               Foreign body 
15. Bilateral infiltrates 
16. Bronchiectasis RML                                       Normal 
17. RUL and LLL pneumonia 
18. Right diffuse infiltrates                                   Foreign body 
19. Bronchial wall thickening RML 
20. LLL Infiltrates                                                Normal 
21. Diffuse infiltrates 
22. RLL infiltrates                                                Foreign body 
23.    Non-calcified nodule                                      Normal  
24.    LLL Infiltrates                                                Normal 
25.    RML consolidation and cavitations                Obstructed main bronchus RML 
26.    Bronchial wall thickening RML, RLL 
27.    Bronchiectasis RML 
28.    Bronchial wall thickening RUL                     Bronchopneumonia 
29.    Bronchiectasis RUL, infiltrates  
30.    Consolidation area in the LSL                       Normal  

Abbreviations: LLL, left lower lobe; LSL, left superior lobe; RLL, right lower lobe; RML, right middle lobe; RUL, 
right upper lobe 

Table 3. Chest imaging and bronchoscopy of the patients with pulmonary hemorrhage. 

and cause of bleeding, and when foreign body aspiration 
was suspected.  

The characteristics and comparison between patients 
with pulmonary and extrapulmonary bleeding is 
presented in the Tables 1 and 2. 

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Pulmonary hemorrhage.  

Among the patients with pulmonary 
hemorrhage (n=30, mean age 7.6), infection or foreign 
body aspiration were the leading etiological causes of 
focal pulmonary hemorrhage. All five patients with 
foreign body aspiration presented themselves more than 
24 hours following the suspected aspiration event. 
Twelve patients with bleeding of pulmonary or bronchial 
origin (40%) had an underlying pathology (Table 3). 
Coagulation function tests and cell blood count were 
abnormal in four patients, one of them with severe gram 
negative sepsis and the other three with severe 
coagulopathy due to fulminant hepatic failure. Cardiac 
evaluation, including echocardiography, was performed 
in 25 patients (those with foreign body aspiration were 
excluded) and revealed a small atrial septal defect in one 
case, and mild pulmonary hypertension in another case. 
Gram negative sepsis was found in one patient and 
candida sepsis in another patient, while the remaining 
patients had negative blood cultures. The cases with 
positive sputum cultures (n=4) revealed mycoplasma, 
mycobacteria, and pseudomonas. Serology for 
mycoplasma (IgG and IgM) was positive in one patient. 
Other serology tests such as antinuclear antibodies and 

antineutrophil cytoplasmic antibodies and complement 
factors were obtained and found to be within the normal 
range in 18 patients. While urinalysis excluded renal 
pathology in all patients, urine toxicology screening 
indicated one case that was positive for cocaine.  

 A positive bronchoscopic finding was observed 
in eight patients with focal findings and hemoptysis as a 
result of pulmonary or bronchial hemorrhage, comprising 
44.5% of the patients in whom bronchoscopy was 
performed. Data on chest imaging and bronchoscopy of 
the patients with hemoptysis are presented in the Table 3.  

Infectious bronchopneumonia was diagnosed in 
nine patients (30%). CT diagnosed bronchiectasis in six 
patients (20% of pulmonary hemorrhage cases, 4.5% of 
all cases). The sweat test for cystic fibrosis was 
uninformative. All patients (n=10) who required 
mechanical respiratory support had diffuse lung 
infiltrates. 

Complete cessation of the hemoptysis was 
observed in 24 patients during their hospitalization 
period (80%), 22 of them achieving complete 
radiological and clinical resolution within four weeks. 
The death of three patients (10%) occurred because of 

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severe sepsis and liver failure, all diagnosed with diffuse 
pulmonary hemorrhage. Three patients were transferred 
to other institutions for surgical treatment and treatment 
of tuberculosis; their long-term outcomes are not known. 
The overall outcome of the remaining patients with 
confirmed pulmonary hemorrhage was good during a 
follow up period of 6-18 months (median 9 months) with 
complete resolution of symptoms.  

Extrapulmonary hemorrhage.   

The group of patients with extrapulmonary 
bleeding (n=104, mean age 5.1 years) differed in terms 
of the presentation and the resolution of the disease. 
Infection or foreign body in upper airways and epistaxis 
(ICD10-CM code R04.0) were the leading etiological 
causes of hemorrhage. In this group, all 12 patients with 
foreign bodies presented during the first 12 hours 
following the suspected event. Endoscopy and 
nasopharyngoscopy data were essential for the diagnostic 
process in all cases. Serology tests such as antinuclear 
antibodies and antineutrophil cytoplasmic antibodies and 
complement factors were obtained and found to be within 
the normal range in 26 patients.  

In this group, complete cessation of the 
hemorrhage was observed in all patients during their 
hospitalization period. A follow up period of 6-18 
months (median nine months) indicated no recurrent 
episodes. 

Correlation data 

No correlation was found between the gender of 
the patients and etiology of the bleeding and diagnostic 
findings (r=0.21 and r=0.32 respectively). The positive 
correlation with younger age (less than six years old) was 
found for the presence of a foreign body at any location 
from nasopharynx and larynx to esophagus and bronchi 
(r=0.83) and idiopathic/traumatic epistaxis (r=0.65). The 
massive aspiration was detected only in the pulmonary 
cases.  

 

Discussion 

Diagnostic code ICD-10-CM R04.2 defines 
hemoptysis as coughing or spitting up blood from the 
respiratory tract with further clarification as 
“expectoration or spitting of blood originating from any 
part of the respiratory tract, usually from hemorrhage in 
the lung parenchyma (pulmonary alveoli) and the 
bronchial arteries.” Our research suggested (Tables 1 and 
2) that pulmonary and extrapulmonary bleeding are two 
conditions that differ significantly and cannot be unified 
under one diagnostic code. In our series of 
extrapulmonary bleeding cases, there were 23 (22%) 
patients with idiopathic or traumatic epistaxis that should 
be encoded as ICD10-CM code R04.0. In pediatric cases; 
however, some blood often proceeds to nasopharynx and 
then presents itself as bloody sputum or cough that can 
mislead a practitioner in correct codification.   

Proper definition for hemoptysis poses both, a 
research/policy problem and a clinical practice challenge. 
Pediatric patients with extrapulmonary bleeding may be 
referred to the departments of otorhinolaryngology or 
maxillo-facial surgery, while patients with pulmonary or 
bronchial hemorrhage are to be admitted to Pediatric 
Intensive Care Unit and/or the department of pediatric 
surgery. In our studies, bloody cough was the presenting 
symptom in 74% of cases. Therefore, the “coughing up 
blood” definition is not entirely correct and further 
clarification of definition for hemoptysis is desirable. For 
example, the most recent study of Simon et al. reported 
prevalence rates for the most common causes of 
hemoptysis in pediatric cases and identified pneumonia, 
bronchitis, and pulmonary tuberculosis as the most 
common specific etiologies.17 In this case, the authors 
used the term “hemoptysis” only in refernce to 
pulmonary or bronchial hemorrhage. 

Extrapulmonary bleeding very rarely leads to 
mortality. Our cases with mortality were related mostly 
to the underlying disease (hepatic failure, sepsis and 
acute respiratory distress syndrome (ARDS)) and less to 
the degree of pulmonary hemorrhage. Patients with poor 

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prognosis that have been described in the literature 
mainly present with diffuse pulmonary hemorrhage in a 
context of autoimmune pulmonary-renal syndrome,18 
which is a combination of glomerulonephritis with 
bleeding in the lungs and is very rare among the pediatric 
population.19 However, we had no cases with renal 
pathology in our study.  

A foreign body aspiration is a specific pediatric 
problem especially in infancy and early childhood. In our 
study, all the participants with foreign body aspiration 
had positive radiological findings, a fact that can be 
explained by their late referral. However, chest 
radiographs may be normal in the first 24 hours following 
foreign body aspiration. The presence of atelectasis, 
pulmonary infiltrates, and a mediastinal shift suggest 
foreign body aspiration.20 

Since cystic fibrosis is the most likely cause of 
bronchiectasis in children, it was ruled out in these 
patients. Efrati et al. described a similar incidence (9%) 
of hemoptysis among Israeli children with bronchiectasis 
due to cystic fibrosis, 12.5% of them requiring bronchial 
artery embolization.21   

Hematologic bleeding diseases are rarely 
associated with hemoptysis and pulmonary hemorrhage 
in children.19 In the current study, 14% of the patients 
with pulmonary hemorrhage suffered from significant 
coagulopathy due to hepatic failure or sepsis. The two 
patients with hepatic failure did not undergo a liver 
transplant due to a high grade of hepatic encephalopathy 
on admission; therefore, the high percentage of 
pulmonary hemorrhage and mortality in these patients is 
explained by the natural course of their liver disease. 

Cocaine abuse was found to be the cause of 
anemia, diffuse pulmonary hemorrhage, and respiratory 
failure in one of our patients (Fig. 1B). Such case is rare 
but similar cases were previously reported describing an 
acute anemia associated with an alveolar hemorrhage 
after inhalation of cocaine.22,23 The pathogenesis is not 
clear yet but an opinion was expressed that cocaine-

induced vasoconstriction, vascular damage in the lung 
tissue, platelet activation, and procoagulatory activity 
could lead to such pathology.  

Hemoptysis related to bacterial, viral, and 
fungal pulmonary infections was previously described.24-

26 We confirmed that such patients may have lobar lung 
infiltrates, concomitant leukocytosis, and high C-reactive 
protein. A study on 21 symptomatic patients with asthma 
revealed hemoptysis in 29% of them.27 Our single 
asthmatic patient presented infiltrates in the middle lobe 
and lingual suggesting the middle lobe syndrome. 
Congenital vascular malformations are relatively rare and 
we only had two such cases. However, these 
malformations can remain unnoticed for a long time. 
Recently, a case was described with a 10-month history 
of recurrent hemoptysis due to unilateral absence of the 
pulmonary artery.28  

Within extrapulmonary cases, laryngeal trauma 
seems to be the most life-threatening cause of bleeding 
because the direct clinical symptoms rarely correlate with 
the degree of respiratory tract failure.29 The idea that 
incidence of extrapulmonary bleeding is significantly 
higher than pulmonary hemorrhage calls to attention to 
these cases and to the differential diagnosis process 
between pulmonary and extrapulmonary hemorrhage. 

Our results demonstrate that the differential 
diagnostics between extrapulmonary and intrapulmonary 
bleeding may be based on significant differences of 
median age, frequency, clinical time-course of foreign-
body aspiration, diffuse infiltration of chest X-ray 
images, and prevalence of severe anemia between the 
two groups. We believe that for pediatric emegency of 
this nature, whatever initial suspicion of a physician on 
duty might be, both a pediatric pulmonologist and a 
pediatric otorhinolaryngologist should be invited for 
consultation. Pediatricians may appreciate the fact that in 
the majority of cases the expectoration of blood-tinged 
sputum has nothing to do with lung diseases. At the same 
time, pediatric ENT specialists should be well prepared 

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to evaluate patient for a serious pulmonary disorder in 
cases of such expectoration. 

While our study was limited to pediatric cases, 
we must point out that while extrapulmonary and 
intrapulmonary bleeding can occur at any age, the 
pediatric cases differ from adult cases and warrant further 
research. For example, the presence of a foreign body in 
the respiratory tract is a very common pediatric problem 
while the lung tumor is extremely rare in children and 
adolescents. Another limitation is that our medical center 
is a large university-affiliated general hospital that does 
not provide pediatric cardiac surgery, transplantation, or 
cystic fibrosis services. This could be the reason why 
patients with these conditions, typically associated with 
bleeding, were not found in the present study.  

While extrapulmonary hemorrhage is the main 
etiology for bloody cough in most of the developed 
countries, developing countries may have other 
experiences with this condition. There are countries 
where pediatric cases of tuberculosis are common. 
Reports from Tunisia, Turkey, and Iran indicate a need to 
provide a differential diagnosis between cases of 
tuberculosis and asthma (pulmonary source of 
hemorrhage) in contrast to allergic rhinitis 
(extrapulmonary source of hemorrhage).30-32 Also, while 
cystic fibrosis is no longer considered the main cause of 
hemoptysis in Israel, this may not be the same in other 
countries.33 Development of the most precise differential 
diagnosis between pulmonary and extrapulmonary 
hemorrhage remains an acute necessity for improvements 
in public health in many countries of the world.  

 

Acknowledgments  

The editing of the final version of the 
manuscript and technical writing support was provided 
by Dr. Michael Shterenshis. 

 

 

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of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 
Central Asian Journal of Global Health 

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VAIMAN 

 
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This journal is published by theUniversity Library System of the University of Pittsburgh as part  

of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 
 

Central Asian Journal of Global Health 
Volume 6, No. 1 (2017) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2017.284|http://cajgh.pitt.edu 

 
 

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	Abstract
	Keywords: Pulmonary Hemorrhage; Extrapulmonary Bleeding; Hemoptysis, Epistaxis; Pediatric
	Research

